The Common Sense Guide to Improving Palliative Care > Preventing, Assessing, and Treating Pain > 4.5 Measuring Success
Whatever your aim, three basic measures can be used in the rapid-cycle process: outcome, process, and adverse effects (also see Chapter 2). For example, Team Faith's outcome measures included pain levels below the patient's own target. For you, process measures might include routine assessment or rapid response time. And adverse-effect measures should be monitored for trouble that stems from your changes (e.g., constipation or delirium).
Decide which data to collect, who will collect it and when, and how and whether to sample the population. Depending on the number of patients with which you are dealing, you may not have enough time to look at every record or patient. Instead, you will need a sampling plan. You also need to decide how often to display your data: weekly, monthly, or quarterly. Be sure to collect enough data to build a case (or to monitor when an improvement is not working).
Once Team Faith had invited key players to join them and had agreed on an aim, they worked out the specifics of how to measure whether their efforts were making a difference.
Measure: Percentage of cancer patients admitted to hospice with pain on their health problem list, who live the rest of their lives with no period longer than eight hours with pain worse than their personal goal.
If you look closely at Team Faith's aim statement, the measure is closely linked to the aim (see above).
Take note of the following specific reasons that are the basis of the aim:
- Some "successful" patients will never have serious pain, while others will have serious pain for less than eight hours. This is a compromise to simplify data collection and evaluation.
- Why lifelong? Because this team had an electronic record system that could readily search for pain worse than personal level and test for relief within eight hours. Cancer patients in hospice overwhelmingly stay in the program until death.
- Why less than patient goal? Some teams might choose an amount less than four (on a 0–10 scale). The standard this team chose is closest to what matters to patients, yet it does require collaborating with patients to establish their pain goal and getting it recorded in the electronic record.
- Why 95% and not 100%? The team knew at the start that the rate was running no better than 50%, so 95% was quite a change. But they also knew that some patients just could not give up their pain for all sorts of reasons, so they did not believe that the "best care" would be 100%.
- Why eight hours? The nurses felt that a 95% success rate would require that most patients were brought under control within a few hours, but they were also aware that no one would want to have to wake up a patient or family member just to confirm success. Also, some situations require trying a few strategies. The team considered 24 hours but rejected that as not being good enough for a promise to patients and families.
Sometimes, collecting data on outcome measures alone is not enough, or it is not possible. You may need to look at the process itself and collect data to check that it is working.
Team Faith decided to start off measuring one process and one adverse effect.
Process measure: Percentage of cancer patients with the patient's target level and their current level of pain recorded with initial vital signs.
Adverse-effect measure: Percentage of cancer patients with opioid medications for whom a successful bowel regimen is continued or a new or improved one started.
Pain improvement teams can choose from many outcomes to measure progress. The following ideas should inspire you to think about what is important in your environment:
- Increased patient confidence in pain relief (outcome).
- Improved pain documentation (process).
- Reduced waiting time for pain medications (process).
- Reduced pain (outcome).
- Eliminated use of meperidine for chronic pain (process).
- Reduced or eliminated errors in changing from one opioid to another (adverse effect).
- Nurse satisfaction with pain management (adverse effect).
Following are some sample measures for improving pain treatment:
- Pain documentation on 100% of admissions.
- Waiting time for inpatient pain medications reduced to less than one hour.
- Rapidly escalating dosage is recognized and leads to palliative care consultation and evaluation within
- Eliminate the use of meperidine for chronic pain.
- Patient survey shows 90% confidence in pain relief.
- After patients' deaths, 85% of families state that there was never a time when pain was out of control.
- Pain of less than five (0–10 scale) within eight hours of pain complaint.
- Eliminate errors in changing from one opioid to another (measure the time between errors).
- Nurses report problems with pain management.